UMEM Educational Pearls

Using radiopaque markers such as paperclips to mark penetrating wounds prior to radiographs has been taught in trauma bays for decades. This article points out there is no evidence to support this practice and is purely based on expert opinion. With the heavy use of CT imaging to assess wound tracks, the use of markers on plain films appears to be of limited utility.

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This retrospective population cohort study looked at  first time ED visits for adolescents and young adults comparing those with visits related to alcohol to those not related to alcohol. Patients in the alcohol related visit group had  a threefold increased one year mortality rate.  Cause of death was trauma, poisoning by drug and alcohol. Risk factors include being male, age 20-29, history of mental health and having a visit for withdrawal.  

Adolescents and young adults presenting to an emergency department for an alcohol related complaint are high risk for one year mortality and deserve intervention and appropriate referral.

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This study compared  admitted trauma patients with alcohol withdrawal or those at risk of withdrawal before and after a  benzodiazepine sparing protocol (using clonidine and gabapentin) was initiated. They found a lower daily CIWA score and significantly less lorazepam use in the benzodiazepines sparing group. This sparing protocol appears to be safe and effective.

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This was a database study of nearly 2 million trauma patients over age 65 who were discharged looking at all levels of trauma centers. The authors found:

“Dominance analysis showed that proportion of patients with Injury Severity Score of >15 contributed most to explaining hospice utilization rates (3.2%) followed by trauma center level (2.3%), proportion White(1.9%), proportion female (1.5%), and urban/rural setting (1.4%).”

 Level one centers had the lowest level of discharge to hospice. The authors felt: “As the population ages, accurate assessment of geriatric trauma outcomes becomes more critical. Further studies are needed to evaluate the optimal utilization of hospice in end-of-life decision making for geriatric trauma.”

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This secondary analysis of the NEXUS head injury data found patients over 65:

-sustained more significant injuries than younger pts

-presented more frequently with occult injuries

-when they required neurosurgery intervention only 16% went home, 32% were discharged to rehab facility and 41%  died

-mechanism of injury was most commonly fall from standing

-mortality rates were highest for fall from ladder and auto vs. pedestrian injuries

The authors concluded: “Older blunt head injury patients are at high risk of sustaining serious intracranial injuries even with low-risk mechanisms of injury, such as ground-level falls. Clinical evaluation is unreliable and frequently fails to identify patients with significant injuries. Outcomes, particularly after intervention, can be poor, with high rates of long-term disability and mortality.”

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This is a retrospective study looking at traumatic brain injury patients comparing those with and without  pre-existing psychiatric illness at the time of injury. Those with pre-existing illness had longer hospital stays, longer ICU stays and more frequent readmissions.

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This meta analysis did not find convincing evidence for or against seizure prophylaxis for admitted moderate to severe traumatic brain injury pts. They recommend Levetiracetam over other medications again on weak evidence.

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In this study, geriatric hip fracture patients with a hemoglobin less than 7.1 had higher mortality, especially in those over age 79, even when controlling for other factors such as ASA Physical status class, anti-platelet use, etc.

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This research letter notes: “The Rural Emergency Hospital is a new Medicare payment model available to hospitals with 50 or fewer beds in rural areas. Rural hospitals converting to this model will have emergency department (ED), observation, and outpatient services.”. Their study concludes that the majority of these hospitals already transfer the vast majority of their admissions to larger hospitals and this designation is a recognition of already established practices.

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This retrospective study of 66 trauma patients who had pelvic fractures attempted to determine if prehospital applied pelvic binders had an impact on mortality. There were 3 cohorts: appropriately applied binders (14), inappropriately applied (14 not at the level of the greater trochanter), and none applied (38).  Survival for applied was 92% and those without was 81% which was not statistically significant.  The authors concluded: “In conclusion, our study found that the use of prehospital pelvic binders did not show a significant effect on patient outcomes for those with unstable pelvic fractures. Instead, injury severity score (ISS) emerged as the most significant predictor of survival.”

Previous studies have shown regular education is needed on proper use of binders.  We should continue to educate on appropriate positioning and the use of pelvic binders. For me, this study is not large enough to convince that we should go away from binder use. We need more data before we abandon the pelvic binder.

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These authors performed a scoping review of English language studies involving United States general surgery patients that required transfer to another facility looking at timing of transfer, triage guidelines, and mode of transport . They concluded: “There were mixed results for the impact of transfer timing on outcomes with heterogeneous definitions of delay and populations. Triage guidelines for EGS transfer were consensus or expert opinion. No studies were identified addressing the mode of interfacility EGS transfer.”  More research is needed in the area concerning timing, triage and mode of transport for these patients.

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In this prospective study looking at geriatric patients with unknown head injury vs. known head injury, the unknown head injury group had an ICH 1.5%, neurosurgical intervention 0.3% and delayed ICH 0.1% when compared to known head injury (10.5%,  1.2% and 0.7% respectively).  The authors concluded that the risk of ICH was high enough in uncertain head injury patients to warrant scanning.

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The question “Would I be surprised if the patient died within the next year”  has been validated as a tool to predict patients with a limited life expectancy. This study looked at trauma team members’ ability to use this question to predict one year mortality. Trauma team members over estimated mortality in this study.

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From the Canadian Medical Protective Association looking at  5 years of closed medical legal cases.  This fits with previous risk management data and should give us pause when treating these conditions.

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Imagine lying in a bed staring at the ceiling and these fuzzy faces looking down on you clearly saying something to you but you can't hear them while your hip and pelvis are hurting worse than anything you have ever felt. That's what many of our fall from standing elderly patients experience in emergency departments on a regular basis. Do not remove glasses or hearing aides from your elderly patients. Work with our EMS colleagues to make it a practice to bring glasses and hearing aides along from the scene.  Speak slowly and get close to their ear to help if necessary. That confusion, delirium or dementia you assume this patient has is actually just hearing impairment and poor vision.

Approaching patients based on their frailty, not their age, leads to better medical decision making. A recent best practice guideline from the American College of Surgeons sums up frailty: 
“It is well recognized that aging is associated with physiological decline, but this decline is not uniform across all individuals or even across one individual’s organ systems. Frailty is a geriatric syndrome, clinically distinct from age, comorbidity, and functional disability, characterized by age- associated depletion of physiological reserves that leads
to a state of augmented vulnerability to physical stressors and a diminished ability to recover from illnesses.” A trauma specific frailty  index exists to identify these high risk patients.

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Since 2014, Medicare has payed for inpatient services for Medicare patients who’s admitting physician noted that hospital stay required at least 48 hours (measured as 2 midnights) or required specialty care that could not be performed as an out patient.  This rule now will apply to Medicare Advantage insurance patients as well. Physicians will need to document their reasoning why a patient’s stay will likely require two midnights.

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As the calendar flips to a new year, consider not setting goals or resolutions. Studies show unmet goals or having too many half finished projects leads to increased stress, anxiety and depression. Instead, consider approaching the new year looking for growth, introspection, and  striving to achieve excellence.  Understanding the why and what motivates you will lead to the correct what and how. Here are some questions to get you thinking about the why.  May your New Year be filled with growth and excellence!  

For the agitated geriatric patient, if verbal deescalation, distraction, and providing a safe quiet area do not work and you require chemical sedation use oral antipsychotics first.  Follow this with IV or IM antipsychotics. Avoid benzodiazepines due to often worsening delirium or respiratory depression. For dosing, start low and go slow.

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NEXUS criteria for blunt chest trauma patients who are over 14 years old, not intubated:

• >60 years old

• rapid deceleration defined as fall > 6 meters or motor vehicle crash >64 km/hour

• chest pain

• intoxication

• abnormal alertness or mental status

• distracting painful injury

• tenderness to chest wall palpation

  If abnormal chest X-Ray proceed to chest CT.  Negative predictive value of 99.9% excluding major injury.

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